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The noncommunicable disease community is unlikely to get everything it was hoping for out of the United Nations High-Level Meeting on NCDs next week, but its leading spokesperson is upbeat nonetheless. “Even if nothing happens in New York, the fact that people are aware of diabetes and other noncommunicable diseases … that there will be a political declaration – a political statement – coming out of New York stating that diabetes and other NCDs are serious, is an achievement in itself,” International Diabetes Federation president Jean Claude Mbanya said at the annual meeting of the European Association for the Study of Diabetes.

Dr. Jean Claude Mbanya / Photo by Miriam E. Tucker

The upcoming 5th edition of the IDF Diabetes Atlas, to be released on November 14th – World Diabetes Day – will include the data that there are 366 million people living with diabetes and 4.6 million deaths due to diabetes – one death every 7 seconds – at a cost of $465 billion spent on diabetes care. In contrast, the last IDF Diabetes Atlas, released in 2009, put the prevalence figure at 285 million. “The cost of not doing something about diabetes is more than the benefit,” said Dr. Mbanya, who noted that IDF is releasing those few figures in advance of the UN NCD summit because “We don’t want the world leaders to forget about diabetes, which is the tsunami of the 21st century.”

In the Political Declaration, which will probably not change during the UN meeting, member states have agreed to establishing NCD plans and policies that create partnerships, to reducing salts and sugars and eliminate industrially produced trans fats in all foods, to increase access to affordable, quality-assured medicines and technologies, to strengthen health care systems to include integration of NCD prevention and treatment, and to increase resources for NCDs. The document also contains an agreement to develop a comprehensive global monitoring framework for NCDs in 2012, and a set of voluntary global targets and indicators.

Items that IDF and the NCD Alliance had pushed for that didn’t make it into the Declaration because of opposition based primarily on budgetary concerns included the specific target of a 25% reduction of NCD deaths by 2025, and a requirement for monitoring. “We think we need targets and measurements. What gets measured is what gets done,” Dr. Mbanya commented.

But, the UN summit isn’t the last step. There will be another evaluation in 2014, just in advance of the scheduled 2015 revision of the Millennium Development Goals. Because many countries base funding decisions on the MDGs, inclusion of NCDs there would be another huge step forward, he said.

For now though, “just getting heads of states to hold a summit on NCDs is an achievement in itself. This will be only the second summit on health after [the 2001 summit on HIV/AIDS]. So, we have achieved something. We have attracted the world’s attention.”

The international noncommunicable disease movement has hit a snag. Negotiations have been delayed in drafting the official Political Declaration for the United Nations High-Level Meeting on the Prevention and Control of NCDs, scheduled for Sept. 19-20. The main issue, according to the NCD Alliance, a lobbying coalition of global NCD-related organizations, is that the United States, Canada, and the European Union are blocking proposals for the inclusion of the specific goal of cutting by 25% all preventable deaths from cancer, cardiovascular disease, diabetes, and chronic respiratory disease by 2025.

In a statement, the alliance said “The situation is urgent. Yet, it is reported that sound proposals for the draft Declaration to include time-bound commitments and targets are being systematically deleted, diluted and downgraded.” The alliance has sent a letter to UN Secretary-General Ban Ki-moon to express “grave concern at the current state of preparations” for the high-meeting, which is to be only the second-ever such UN meeting focusing on a global health issue. The first one, on HIV/AIDS in 2001, is credited with spurring global political, social, and financial action to address that problem.

According to the alliance, language about “action-oriented outcomes” is being replaced with “vague intentions” to “consider” and “work towards” NCD reduction goals, moves they deem “simply unacceptable.” Along with the 2025 goal, the letter reiterates previous demands that UN member states must develop a set of specific, evidence-based targets and global indicators, a clear time line for tackling the epidemic of the four major NCDs, and “a high-level collaborative initiative of government and UN agencies with civil society to stimulate and assess progress.”

In an interview with Reuters, NCD chair Ann Keeling said that money was the main sticking point, with wealthier nations reluctant to commit to paying for chronic disease care in poor countries at a time when even “rich” economies are in a downturn. Indeed, the sum is considerable, as NCDs now account for 63% of all deaths worldwide and half of all global disability, posing a serious threat to development in many lower-income nations. “The reason we called for a UN summit in the first place was to move toward a global action plan…The world is essentially sleepwalking into a sick future,” said Ms. Keeling, who is also chief executive officer of the International Diabetes Federation.

Negotiations on the Political Declaration are set to resume Sept. 1. In the meantime, the IDF has recently launched a postcard campaign urging President Obama to attend the high-level meeting, which is expected to draw heads of state from many UN member nations. The IDF has also organized a rally – with the support of several U.S.-based diabetes organizations and bloggers and other international NCD-related groups – to be held in New York City’s Central Park on Sunday, Sept. 18 to raise public awareness about the worldwide impact of NCDs.

Before last week, I thought I knew the definition of “noncommunicable disease.” Then I attended “The Long Tail of Global Health Equity: Tackling the Endemic Non-Communicable Diseases of the Bottom Billion.”

Held on the campus of Harvard Medical School in Boston March 2nd and 3rd, the 2-day conference was sponsored by Partners In Health, an international nonprofit organization that conducts research, does advocacy, and provides direct health care services for people living in poverty around the world. The “Bottom Billion” of the meeting’s title refers to the world’s poorest people living on less than $1 per day.

In a 2008-2013 action plan, the World Health Organization refers to “the four noncommunicable diseases – cardiovascular diseases, diabetes, cancers and chronic respiratory diseases and the four shared risk factors – tobacco use, physical inactivity, unhealthy diets and the harmful use of alcohol.” Together, these conditions account for approximately 60% of all global deaths, of which 80% occur in low- and middle-income countries.

A cancer patient in Rwanda receives chemotherapy as her husband and physician discuss her treatment / Photo courtesy of Partners In Health

And most startling to me: Among the world’s poorest, smoking is not the most common cause of chronic obstructive pulmonary disease. Cooking with biomass fuels is.

Individually, these and other so-called “endemic NCDs” including Burkitt’s lymphoma, sickle cell disease, and tropical diseases are far less common than those within the WHO’s “four-by-four” definition. But together, that “long tail” of chronic conditions contributes to a great deal of suffering.

In May 2010, the United Nations announced that it would hold a high-level meeting on NCDs in 2011, now set for September 19-20. It will be only the 29th such meeting that the UN has ever held (formerly called “special sessions“), and just the second pertaining specifically to a health issue. The first one, the 2001 Summit on HIV/AIDS, is credited with focusing global attention and obtaining public and private funding for that cause.

Speakers at the Partners In Health meeting stressed that the NCD movement should not be undertaken as an “us against them” competition with infectious disease for scarce resources. In a statement that will be presented to the heads of government at the UN summit, the group called instead for “strengthening and adjusting health systems to address the prevention, treatment, and care of NCDs, particularly at the primary health care level.”

With the United Nations summit on noncommunicable disease less than a year away, Members of the European Parliament (MEPs) have now contributed to a growing number of voices worldwide calling for urgent action to address the chronic disease epidemic.

Image by Pacopus via Flickr Creative Commons

In a statement sent this week to the Presidency of the European Union, four MEP groups wrote, “Chronic non-communicable diseases account for 86% of deaths in the WHO European Region. They include heart disease, stroke, hypertension, diabetes, kidney disease, cancers, respiratory and liver diseases. Because most are treatable but not always curable, they generate an enormous financial burden due to treatment costs, care costs and loss of productivity.”

Signatories are the MEP Heart Group, the EU Diabetes Working Group, the MEP Group for Kidney Health and MEPs Against Cancer, informal groups of parliament members engaged in fighting the diseases and conditions in those health areas.

The MEPs note that chronic noncommunicable diseases (NCDs) affect more than a third of Europe’s population, comprising over 100 million citizens, and that four preventable health determinants – tobacco use, poor diet, alcohol consumption, and lack of physical activity – account for most of chronic illness and death in Europe. Prevention costs less than disease management and treatment, yet 97% of health expenses currently are spent on treatment and only 3% invested in prevention.

The statement advises EU member states to follow recommendations from a policy paper entitled “A Unified Prevention Approach.” That 20-page document was issued in July by the Chronic Disease Alliance, a coalition of 10 separate European nonprofit professional medical organizations, including those representing hepatology, oncology, cardiology, nephrology, respiratory medicine, and diabetology.

The Alliance’s recommendations include a call for harmonization of tobacco taxation across Europe, standardization of cigarette packaging with 80% of the package devoted to pictorial health warnings, and a ban of tobacco sales via the Internet and vending machines.

They also recommend a ban of added trans fat to foods, introduction of a traffic light color coding system to food labels (with green being the most healthful and red the least), increased access to affordable fresh fruit and vegetables, and EU measures to prohibit marketing of unhealthful food to children. Other recommendations address the promotion of physical activity and the reduction of alcohol consumption and dependence.

According to the Alliance, “Simple policies could save millions of lives and cut billions of euros in direct and indirect costs…By acting now, the European Commission will be doing something that transcends anything else it may accomplish.”

During the EASD meeting in Stockholm last week, I spoke with International Diabetes Federation (IDF) CEO/executive director Ann Keeling about recent progress in efforts to focus attention on the global health epidemic of noncommunicable disease (NCD). Ms. Keeling had flown to Stockholm from New York, where she attended an NCD side panel event held during the United Nations’ 2015 Millennium Development Goals (MDGs) Summit.

Photo of Ann Keeling taken by Miriam E. Tucker

Unlike the sparsely attended UN NCD panel in April, this one was packed. “It was amazing. There were something like 200 people in the room. Senior government people were making strong statements about NCDs,” she told me.

Why the difference? In May, the UN announced a resolution—sponsored by 130 countries—to hold a special Summit on NCDs in September 2011. Just as the UN Summit on HIV/AIDS in 2001 brought attention and international aid to that cause, the NCD summit is expected to focus the world’s attention on the emerging epidemics of diabetes, cancer, heart disease, and tobacco use that are disproportionately affecting poor and middle-income nations in terms of both health and wealth.

Ms. Keeling chairs the NCD Alliance, a coalition comprising the IDF, the World Heart Federation, the Union for International Cancer Control, and the International Union Against Tuberculosis and Lung Disease. Formed in May 2009, the Alliance had lobbied for the UN NCD Summit. Now, with a year to go, it is gearing up for it. Last week the Alliance issued an official plan of action leading up to the Summit.

Over the next year, the Alliance will continue to lobby governments and the private sector to raise awareness of NCDs, including arguing the business case for investing in prevention and treatment. The fact that NCDs affect working-age adults means that economies are threatened, Ms. Keeling said. “In a generation, there will be cities full of sick people and a sick workforce. This has huge implications for competitiveness.”

The current 2015 MDGs, which do not mention NCDs, are falling short. The Alliance is calling for NCD indicators to be included in successor goals aimed beyond 2015 but not to wait until then to act, as some governments have suggested. “Why on earth would you wait 5 years? We have a real chance to intervene in Africa, where obesity and diabetes are rising fast. If we can start now, we can head off something that would be so much worse in 5 years’ time.”

Photo taken in Tanzania by Jen Wen Luoh / via Flickr Creative Commons

Two additional events last week reflect increased recognition of the importance of NCDs. The Organisation for Economic Co-operation and Development (OECD), which influences developing nations on spending priorities, issued a report entitled “Health: OECD says governments must fight fat,” describing with stark statistics the rising burden of obesity worldwide.

And last week during the Clinton Global Initiative, Medtronic announced a $1 million grant to the NCD Alliance in preparation for the 2011 Summit. That’s significant, Ms. Keeling said. “When companies and philanthropists put big pledges on the agenda, it signals what’s important.”

International nongovernmental health organizations are celebrating the United Nations General Assembly’s May 13th decision to hold a special summit on non-communicable disease in September 2011.

The summit has been a major priority for the International Diabetes Federation (IDF), the World Heart Federation, the International Union Against Cancer, and the International Union Against Tuberculosis and Lung Disease, which have campaigned together for it. These diseases are responsible for 35 million annual deaths globally, 80% of which occur in low- to middle-income countries.

There have been only 28 such special UNGA summits (formerly called “special sessions”) in UN history. The one on HIV/AIDS in 2001 significantly influenced political action for that crisis. To this point, noncommunicable disease has not been considered a world health priority and is not included in the Millenium Development Goals, despite increasing evidence that chronic conditions threaten economic development as well as health in the developing world.

The idea for the NCD summit is credited to former IDF President Dr. Martin Silink. I interviewed Dr. Silink last July. He said that such a high-level session would be the best way to communicate to world governing bodies the profound threat of the NCDs and the need for political action to combat them.

Dr. Martin Silink photo courtesy of the International Diabetes Federation

“This is a development issue affecting so many countries. The development of health systems is so dependent on donor country support that donor countries must also help to drive the agenda…We feel this can only be truly understood if there’s time to debate it properly. A special session would be the right forum to do this.”

Ultimately, he said, the aim is to improve care for people living with chronic conditions, but not in the same way as has been done with HIV/AIDS. “What we are not calling for is a new vertical system as has been established for HIV/AIDS. We are calling for the strengthening and development of primary health care systems, and to have the NCDs inserted into those systems.”

On a global scale, noncommunicable diseases such as diabetes, cancer, and heart disease don’t just threaten health, but also development.

That’s how speakers framed the discussion at a World Health Organization panel on noncommunicable disease (NCD), held at the United Nations as a side session during the 43rd Session of the Commission on Population and Development (CPD).

Sir George Alleyne, director emeritus of the Pan American Health Organization, led off by calling NCDs a “major burden in terms of morbidity and mortality” in the developing world and a “neglected disease priority.”

Yet, 80% of NCDs can be controlled or prevented by reducing common risk factors such as tobacco use, unhealthful diets, and inactivity, measures addressed in the WHO’s 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases.

Dr. Rachel A. Nugent, deputy director for global health at the Center for Global Development, said that unlike infectious disease, which hits children and the elderly the hardest, NCDs primarily affect adults of working age. This in turn leads to reduced productivity and economic loss in developing nations.

A 2007 study found that a 10% increase in cardiovascular disease mortality among the working-age population decreases the per capita income growth rate by about 1 percentage point. Between 2006 and 2015, that loss is projected to total $84 billion (in U.S. dollars) worldwide.

“Even if health and social losses aren’t enough to compel us to action—and they are—the potential economic losses should move us to action,” Dr. Nugent said.

Dr. Gauden Galea of the WHO’s chronic disease division outlined the links between NCDs and infectious disease. For example, people with diabetes have a threefold increased risk for developing active tuberculosis, slightly more than the relative risk for active smokers.

According to a recent study, a 10% reduction in the death rate from NCDs would have a similar impact on progress toward TB eradication goals as would a rise in gross national product corresponding to at least a decade of growth in low-income countries.

Dr. Laurent Huber, director of the Framework Convention Alliance, an international antitobacco coalition, said his organization has joined forces with several international health groups and nongovernmental organizations to push for action on NCDs.

The coalition has two main priorities. One is inclusion of NCD indicators in the UN’s Millennium Development Goals (MDGs). Currently, the MDGs—the blueprint for world development that guides funding decisions—don’t even mention NCDs. An MDG Review Summit is slated for September 2010.

The other priority—also endorsed by the Commonwealth of Nations and the Caribbean Community—is a September 2011 UN General Assembly Special Session (UNGASS) on NCDs to raise political awareness of the issue, just as a 2001 UNGASS did for HIV/AIDS.

Dr. Alleyne, a Barbados-born physician who was knighted by Queen Elizabeth in 1990, sees the NCD UNGASS not just as a priority but a necessity. “This has to happen,” he told me when I spoke with him briefly after the session ended. “We need a push. This has to happen.”